IMAGING IN LUNG CANCER

IMAGING IN LUNG CANCER

1. Radiological evaluation in cancer lung DR KANHU CHARAN PATRO MD,DNB(RADIATION ONCOLOGY),MBA,FICRO,FAROI(USA),PDCR,CEPC HOD,RADIATION ONCOLOGY Mahatma Gandhi Cancer Hospital And Research Institute, Visakhapatnam [email protected] /M- [phone]-Aug-23 7:53:18 AM 1

2. Ammunitions CXR CECT CHEST MRI PET 2

3. What to see? 3

4. RADIATION ONCOLOGISTS PREVIEW 4

5. SURGICAL ONCOLOGISTS PREVIEW 5

6. MEDICAL ONCOLOGISTS PREVIEW 6

7. New staging 7

8. 8

9. 9

10. 10

11. lung Primary lesion 11

12. 14 Imaging features : T1 T1: Tumor < 3 cm, Not proximal to lobar bronchus Surrounded by lung or visceral pleura 12

13. T1 13

14. 15 Imaging features : T2 T2 : Tumor > 3 cm, main bronchus > 2 cm from carina Visceral pleura invasion Atelectasis,consolidation not inv entire lung 14

15. T2 15

16. 16 Imaging features:T3 An y size with inv chestwall/med pleura/ parietal pericardium /diaphragm main bronchus inv <2cm from carina Atelectasis,consolidation entire lung Lesion abutting chest wall and invading the visceral pleura, Endobronch lesion at Lt.UL bronchus . Left upper lobe collapse Atelectasis ext to hilar region 16

17. T3-IMAGING 17

18. Imaging features:T4 Invasion of mediastinum , heart, great vessels, trachea, esophagus , vertebral body, carina Satellite tumor nodules OTHER LOBE 18

19. T4 19

20. Remember Same lobe extra nodule- T3 Same lung extra nodule –T4 Different lung extra nodule- M1 20

21. NODAL STATIONS 21

22. 22

23. 23

24. Lymph nodes 24

25. Supraclavicular & upper paratracheal 25

26. Prevertebral & prevascular 26

27. Lower paratracheal 27

28. Subaortic & para aortic 28

29. Carinal , paraoesophageal & hilar 29

30. 30

31. 31

32. 32

33. 33

34. 34

35. 35

36. 36

37. 37

38. 38

39. 39

40. 40

41. 41

42. 42

43. Remember Double digit lymph node level-N1 Single digit lymph node level - N2[2-9] Opposite out side thoracic and – N3[1] 43

44. N1-GROUP-10 44

45. N1-HILAR-GROUP 10 45

46. N2-UPPER PARATRACHEAL 46

47. N2-MEDIASTINAL Stage N2 lymph nodes. (a) Chest CT scan shows an enlarged (1.6-cm) right upper paratracheal lymph node (level 2) (arrowhead ). (b) Chest CT scan obtained in a different patient shows an enlarged (1.5-cm) right lower paratracheal lymph node (level 4) (arrowhead). (c) Chest CT scan obtained in a third patient shows a right lower lobe mass (white arrow) with an enlarged (1.6-cm) subcarinal lymph node (level 7) (black arrow ) 47

48. N3 Stage N3 lymph nodes. (a) Axial PET/CT image of the chest shows a primary mass in the left lung (arrow) and a right lower paratracheal lymph node (arrowhead), both of which demonstrate intense radiotracer uptake. Metastatic involvement of the lymph node was confirmed at mediastinoscopic resection. (b) Chest CT scan obtained at the lung apex in a different patient shows enlarged bilateral supraclavicular lymph nodes (arrows). 48

49. Characteristics of various histology 49

50. Malignant nodule Corona radiata sign in a malignant lesion with spiculation at the margin. 50

51. 51

52. Calcification in 7% on CT (histologically in 14%) usually eccentric / finely stippled Preexisting focus of calcium engulfed by tumor Dystrophic calcium within tumor necrosis Calcium deposit from secretory function of carcinoma ( e.g. mucinous adenocarcinoma) Malignant Calcifications 52

53. Tumor calcification Large bronchial carcinoma invading the mediastinum demonstrates coarse and cloud-like calcification. 53

54. Alveolar cell carcinoma Bronchiolar or bronchio -alveolar Ca Subtype of adeno Ca Peripherally , probably from type II pneumocytes May be associated with diffuse pulmonary fibrosis and pulmonary scars CT : ground glass opacification , small nodular opacities, frank consolidation, thickened interlobular septa 54

55. 55

56. Early stage (due to lepedic growth pattern along alveolar septa with relative lack of acinar filling) Ground-glass haziness Bubble-like hyperlucencies / pseudocavitation Airway dilatation Lesion persists / progresses within 6-8 weeks Ground glass haze 56

57. Alveolar cell carcinoma 57

58. local hyperaeration (due to check-valve type endobronchial obstruction , best on expiratory view) CT shows dilated, fluid-filled bronchi in the right middle lobe, secondary to carcinoma at the right hilum. Local hyperaeration also seen. Local Hyperaeration 58

59. Bronchocele -alveolar carcinoma 59

60. Refers to vessels appearing prominent during a contrast enhanced CT as they traverse an airless low attenuation portion of consolidated lung CT Angiogram Sign 60

61. Small cell carcinoma Chest CT scan demonstrates a spiculated nodule in the right upper lobe. (b) Contrast enhanced chest CT scan ( mediastinal window) shows massive mediastinal lymphadenopathy secondary to lymph node metastases. 61

62. LARGE CELL CARCINOMA Large peripheral mass of solid attenuation and irregular margin . Focal necrosis can be present. Other characteristics include rapid growth 62

63. Large mass in large cell carcinoma 63

64. ADENO -CARCINOMA LUNG Radiographic features Peripheral location Sometimes it is impossible to radiographically distinguish between other histological lung cancer types. 64

65. Adenocarcinoma Adenocarcinoma in a 41-year-old man with right shoulder pain for several months. (a) Apical fibrootic chest radiograph demonstrates a right apical mass with poorly marginated borders. (b) Chest CT scan (lung window) shows a homogeneous peripheral right upper lobe mass with irregular borders. There is tumor involvement of a posterior rib (arrow). 65

66. SQUAMOUS CELL CARCINOMA Chest radiograph The appearance depends on the location of the lesion..When the right upper lobe is collapsed and a hilar mass is present, this is known as the  Golden S sign.  A more peripheral location may appear as a rounded or spiculated mass. Cavitation may be seen as an air-fluid level. A  pleural effusion  may also be seen, and although it is associated with a poor prognosis, 66

67. CT scout film shows abrupt cut off of right main bronchus with collapse of right lung and mediastinal shift. CT shows a mass arising and obliterating the right main bronchus Bronchial cut-off sign 67

68. Cavitary lesion in squamous cell 68

69. THE GOLDEN S SIGN 69

70. Left upper lobe collapse due to bronchial carcinoma. Carcinoma has caused rat tail like narrowing of left upper main bronchus Rat tail termination of bronchus 70

71. Metastatic lung disease feeding vessel sign 71

72. TREE IN BUD SIGN-POST RADIATION 72

73. NODULAR RADIATION PNEUMONITS 73

74. GROUND GLASS PATTERN –POST RT 74 Ground - glass opacity  (GGO) is a radiological term  indicating  an area of hazy increased lung  opacity  through which vessels and bronchial structures may still be seen

75. RADIATION FIBROSIS 75

76. SCAR LIKE PATTERN-POST RT 5 YEAR 76

77. SUSPICIOUS CONDITIONS 77

78. Nodule in other lobe/satellite 78

79. Atlectesis /Consolidation/tumor 79

80. Intra and inter observer variation 80

81. Rib and chest wall invasion 81

82. Suspicious node 82

83. WHEN IT IS UNCLEAR THINK OF NUCLEAR 83

84. 84

85. WHY PET Morphological and functional characterization of pulmonary nodules or masses; Differentiation tumor vs atelectasis For tumor-node-metastasis ( TNM ) staging of the mediastinum Screening for metastases that might not be detected by CT alone For radiotherapy planning 85

86. Where is the Target? 86

87. Suspicious satellite nodule 87

88. Differentiating atelectsis and mass 88

89. Suspicious chest wall invasion 89

90. Rib and chest wall invasion-MRI 90

91. Suspicious node 91

92. Suspicious prevertebral node 92

93. 93

94. PET-CT-WIN-WIN SITUATION PARAMETER VOLUME CHANNGE T STAGE UPSTAGING PREVENTS TUMOR TISSUE MISSING CHANGES TT FROM CURATIVE TO PALLLIATIVE DOWN STAGING PREVENTS EXTRA DOSE TO NORMAL TISSUE CHANGES TT. FROM PALLIATIVE TO CURATIVE DOSE ESCALATION IS POSSIBLE N STAGE UPSTAGING PREVENTS TUMOR TISSUE MISSING CHANGES TT FROM CURATIVE TO PALLLIATIVE DOWN STAGING PREVENTS EXTRA DOSE TO NORMAL TISSUE CHANGES TT. FROM PALLIATIVE TO CURATIVE DOSE ESCALATION IS POSSIBLE M STAGE UPSTAGING CURATIVE-TO PALLIATIVE DOWN STAGING PALLIATIVE TO CURATIVE 94

95. 95

96. Bird’s eye view Eagle’s eye view 96

97. 97